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SANA N J O A O U I N Environmental Health Department <br /> COUNTY— <br /> Example:OUN T.,�Y <br /> Example: <br /> .11-ADE IN A HOME IOTCHEN <br /> Permit=: 13345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Salty Baker <br /> 133 Cottage Food Lane <br /> Anywhere_CA 90.Lti\ <br /> Ingredients: Enriched flour(1t'heat flour.niacin.reduced iron.thiamine. <br /> nuntotutrate.riboflavin and folic acid).butter(milk,salt).chocolate chips <br /> (sugar.chocolate liquor,coeur bunter,butterfat(utilk). walums.su«ar.e!,�-,s. <br /> salt.artificial vanilla extract.baking soda. <br /> Contains:Wheat,eggs.milk,soy,ivahtuis <br /> \et Wt.3 oz.(85.(49-) <br /> Note:For the"Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> Public Sewer Service ❑ Private Septic System <br /> In the event of septic system failure or plumbing problem,you are required to notify San Joaquin County Environmental Health Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District: CSL wf\-rz�P_ <br /> ❑ Private Water Supply—, Identify the source (well, spring, surface, etc.): <br /> Private Water Supply:Initial Water Quality Results <br /> Check boxes below if initial water testing has been completed. <br /> All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab,date& <br /> results in space provided next to type of test. <br /> *(Testing frequency for transient Non-Community Water Systems after initial testing) <br /> ❑ Bacteriological Test(quarterly*): <br /> ❑ Nitrate Test(yearly*): <br /> ❑ Nitrite Test(every 3 years*): <br /> —Additional information may be required if food is prepared from a home with a private water supply—check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: <br /> Within 3 months of being approved to operate by the Environmental Health Department, please p vide proof <br /> of completion of the California Food Handler course in lieu of the California Department of Public Health <br /> (CDPH) food processor course. <br /> For more information see CDPH website www.cdph.ca.gov/programs/PageslfdbCottageFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />